DMEC CLMS COMPREHENSIVE
ASSESSMENT 2026 FULL CASE
SCENARIOS ACCURATE SOLUTIONS
EXPERT REVIEW
◉ Prospective Payment System.
Answer: Used by Medicare-participating hospitals: pretreatment
diagnosis billings based on DRGs; rate decided ahead of time
between insurance companies and hospitals
◉ Exclusive Provider.
Answer: Used by HMO's: insurance coverage for contracted
providers or institutions
◉ HMOs.
Answer: Health maintenance organizations: comprehensive
healthcare to people who pay a fee for a fixed period of time
◉ Capitation.
Answer: Fixed rate paid to provider per member per month for
healthcare services; set fee paid by insurance company per month
for all the patient needs
,◉ PPOs.
Answer: Preferred provider organizations: special reduced rate for
services when customers use certain providers approved by the
insurance company; usually fee-for-service
◉ IPAs.
Answer: Individual provider arrangements: provide care in their
offices for prepaid plans; coalition of physicians who serve HMO
patients and third-party patients
◉ Fulltime FTE Hours.
Answer: 2080 hours (1.0 @ 40 hours per week)
◉ Capital Expenses.
Answer: Long-term equipment or physical purchases: usually over
$500-$1000 that will last years and depreciate over time and be
used multiple times
◉ Zero-Based Budget.
Answer: With each new budget (i.e. fiscal year), it is determined
which programs/areas get money; no historical context is used; may
rank packages and then only fund top-ranked ones; can be time-
consuming way to create a budget
,◉ Variance Calculation & Reminders.
Answer: Variance $ /Budgeted $ X 100 = % difference; contract staff
on separate line of budget; many staff sick costs more than a few
staff on LOA
◉ Cost of Nursing Services Calculation.
Answer: Nurse Time X (Avg. RN Hourly Rate + Benefits + Indirects) =
Total Nursing Cost per DRG
◉ General Nurse Staffing Calculation.
Answer: # of RNs needed X days open / # days worked per RN
◉ FTE Definition & Calculation.
Answer: Full-time equivalent = full-time employee paid for 1 year
FTE = (Hours per shift X # of days worked) / 40 hours
◉ Fixed Costs.
Answer: Stay the same no matter the census: manager salaries,
keeping phones on, rent, etc.
◉ Variable Costs.
, Answer: Change with census and how much staffing is used
◉ Net Revenue Calculation.
Answer: Gross Revenue - Deductions from Revenue (DRGs and the
Contractual allowances paid by insurance companies)
◉ UAP.
Answer: Unlicensed assistive personnel (CNA's)
◉ ADC.
Answer: Average daily census (patients in a bed at midnight)
◉ Total Patient Days Calculation.
Answer: ADC X Days open per year (for SCH - ADC X 365)
◉ Nurse Hours Per Patient Day (HPPD) Calculation.
Answer: Total Direct Care Hours / Total Patient Days = # of RN hours
needed to provide care for a pt. for 24 hours.
For example - for 12 hour staff and 12 workers each shift you
multiply 12 staff X 2 shifts = 24 staff X 12 hours each = 288 divided
by midnight census of 31 = NHPPD
ASSESSMENT 2026 FULL CASE
SCENARIOS ACCURATE SOLUTIONS
EXPERT REVIEW
◉ Prospective Payment System.
Answer: Used by Medicare-participating hospitals: pretreatment
diagnosis billings based on DRGs; rate decided ahead of time
between insurance companies and hospitals
◉ Exclusive Provider.
Answer: Used by HMO's: insurance coverage for contracted
providers or institutions
◉ HMOs.
Answer: Health maintenance organizations: comprehensive
healthcare to people who pay a fee for a fixed period of time
◉ Capitation.
Answer: Fixed rate paid to provider per member per month for
healthcare services; set fee paid by insurance company per month
for all the patient needs
,◉ PPOs.
Answer: Preferred provider organizations: special reduced rate for
services when customers use certain providers approved by the
insurance company; usually fee-for-service
◉ IPAs.
Answer: Individual provider arrangements: provide care in their
offices for prepaid plans; coalition of physicians who serve HMO
patients and third-party patients
◉ Fulltime FTE Hours.
Answer: 2080 hours (1.0 @ 40 hours per week)
◉ Capital Expenses.
Answer: Long-term equipment or physical purchases: usually over
$500-$1000 that will last years and depreciate over time and be
used multiple times
◉ Zero-Based Budget.
Answer: With each new budget (i.e. fiscal year), it is determined
which programs/areas get money; no historical context is used; may
rank packages and then only fund top-ranked ones; can be time-
consuming way to create a budget
,◉ Variance Calculation & Reminders.
Answer: Variance $ /Budgeted $ X 100 = % difference; contract staff
on separate line of budget; many staff sick costs more than a few
staff on LOA
◉ Cost of Nursing Services Calculation.
Answer: Nurse Time X (Avg. RN Hourly Rate + Benefits + Indirects) =
Total Nursing Cost per DRG
◉ General Nurse Staffing Calculation.
Answer: # of RNs needed X days open / # days worked per RN
◉ FTE Definition & Calculation.
Answer: Full-time equivalent = full-time employee paid for 1 year
FTE = (Hours per shift X # of days worked) / 40 hours
◉ Fixed Costs.
Answer: Stay the same no matter the census: manager salaries,
keeping phones on, rent, etc.
◉ Variable Costs.
, Answer: Change with census and how much staffing is used
◉ Net Revenue Calculation.
Answer: Gross Revenue - Deductions from Revenue (DRGs and the
Contractual allowances paid by insurance companies)
◉ UAP.
Answer: Unlicensed assistive personnel (CNA's)
◉ ADC.
Answer: Average daily census (patients in a bed at midnight)
◉ Total Patient Days Calculation.
Answer: ADC X Days open per year (for SCH - ADC X 365)
◉ Nurse Hours Per Patient Day (HPPD) Calculation.
Answer: Total Direct Care Hours / Total Patient Days = # of RN hours
needed to provide care for a pt. for 24 hours.
For example - for 12 hour staff and 12 workers each shift you
multiply 12 staff X 2 shifts = 24 staff X 12 hours each = 288 divided
by midnight census of 31 = NHPPD
